Role Description Acentra Health is looking for a Clinical Reviewer - RN - PRN (Remote U.S.) to join our growing team. Job Summary:

• Review medical records against criteria, contract requirements, and regulatory standards.
• Employ critical thinking to determine medical appropriateness while meeting production goals and QA standards.
• Ensure day-to-day processes align with NCQA, URAC, CMS, and other regulatory benchmarks.

Responsibilities:

• Review and interpret patient records to determine medical necessity and appropriateness of care.
• Initiate referrals to the physician consultant and process decisions, ensuring detailed correspondence for denials.
• Abstract review-related data/information accurately and promptly using appropriate review tools.
• Ensure accurate and timely submission of all administrative and review-related documents.
• Perform ongoing reassessment of the review process to identify improvement opportunities.
• Foster positive and professional relationships with internal and external customers.
• Attend training and scheduled meetings, maintaining current information for review.
• Maintain medical records confidentiality by adhering to HIPAA policies.
• Utilize proper telephone etiquette and follow company communication guidelines.
• Actively cross-train to perform duties of other contracts within the company network.
• Read, understand, and adhere to all corporate policies, including HIPAA policies.
• * Preferred availability is during business hours (8:00 AM–5:00 PM, Monday–Friday). We can be flexible with scheduling based on individual availability. Occasional weekend coverage may be requested as needed. **

Qualifications

• Active, unrestricted Registered Nurse (RN) License in South Carolina, or an RN compact state license.
• Associate’s, Bachelor's degree (or Diploma) in Nursing.
• 2+ years of clinical experience in an acute or med-surgical environment.
• 1+ years of work experience in Utilization Review (UR), Utilization Management (UM), or Prior Authorization.
• 1+ years of knowledge of InterQual criteria.
• Remote work experience.

Requirements

• Knowledge of Utilization Review Accreditation Commission (URAC) standards.
• Knowledge of Medicare (CMS) guidelines.
• Medical Record Abstracting skills.
• Clinical assessment and critical thinking skills.
• Excellent verbal and written communication skills.
• Ability to work in a team environment.
• Flexibility and strong organizational skills.
• Proficient in Microsoft Office and Internet/Web Navigation.

Benefits

• Access to select Acentra Health benefits and programs.
• Participation in the Acentra Health 401(k) Plan with company match.
• Access to wellness and employee discount programs.
• Employee Assistance Program (EAP) resources.

Compensation

The pay range for this position is listed below. “Based on our compensation philosophy, an applicant’s position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.” Pay Range: USD $28.37 - USD $36.00 /Hr.